STRESS MANAGEMENT:Medication, Behavioral and Cognitive Methods

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Health Psychology PSY408

Lesson 22

STRESS MANAGEMENT

In our previous lecture, we discussed several methods that are helpful in reducing the potential for stress

and, thereby, benefiting health. These methods take advantage of the stress-moderating effects of social

support, personal control, exercise, being well organized, and being prepared for an impending stressor. In

this lecture we will consider ways to reduce the reaction to stress once it has begun.

Reducing Stress Reactions: Stress Management

People acquire coping skills through their experiences, which may involve strategies they have tried in the

past or methods they have seen others use. But sometimes the skills they have learned are not adequate for

a current stressor because it is so strong, novel, or unrelenting. In some cases, the approaches they have

acquired reduces stress in the short run-- as alcohol or cigarette smoking can do--but are not adaptive and

increase stress in the long run. These problems in coping often arise in individuals whose potential for stress

is high because of a lack of social support, personal control, and so on; but coping problems also happen

among people whose potential for stress is relatively low. When people cannot cope effectively, they need

help in learning new and adaptive ways of managing stress.

Many techniques are available to help individuals manage stress. These stress management techniques are

mainly psychological, but pharmacological approaches are also used sometimes under medical supervision.

Medication

Of the many types of drugs physicians prescribe to help patients manage stress, we will consider two:

Benzodiazepines and Beta-blockers.

Both of these drugs reduce physiological arousal and feelings of anxiety. Benzodiazepines appear to work by

activating a neuro-transmitter that decreases neural transmission in the central nervous system. Beta-

blockers appear to block the activity of sympathetic neurons in the peripheral nervous system that are

stimulated by epinephrine and nor-epinephrine.

Beta-blockers cause less drowsiness than benzodiazepines, probably because they act on the peripheral

rather than central nervous system. Using drugs to manage stress should be only a temporary measure,

either to help during an acute crisis, such as in the week or two following the death of a loved one, or while

the patient learns new psychological methods for coping. But more and more people are relying on drugs

for long-term control of their stress and emotions.

Behavioral and Cognitive Methods

Psychologists have developed methods they can train people to use in coping with stress. Some of these

techniques focus mainly on the person's behavior, and some emphasize the person's thinking processes.

People who use these methods usually find them helpful.

Relaxation

The opposite of arousal is relaxation--so relaxing should be a good way to reduce stress. "Perhaps so, you

say, but when stress appears, relaxing is easier said than done. Actually, relaxing when under stress is not so

hard to do when you know how. One technique people can learn to control their feelings of tension is

called progressive muscle relaxation (or just progressive relaxation), in which they focus their attention on

specific muscle groups while alternately tightening and relaxing these muscles.

The idea of teaching people to relax their skeletal muscles to reduce psychological stress was proposed

many years ago by Edmund Jacobson (1938). He developed a device to measure electrical activity in muscle

fibers. Using this device, he found that people would reduce the tension in their muscles when simply asked

to "sit and relax." He later found that muscle tension could be reduced much more if the subjects were

Health Psychology PSY408

taught to pay attention to the sensations as they tense and relax individual groups of muscles. Research

findings indicate that one reason muscle relaxation reduces psychological stress is that the technique tends

to arouse pleasant thoughts in the person.

Although there are various versions of the progressive muscle relaxation technique, they each outline a

particular sequence of muscle groups for the person to follow. For example, the sequence might begin with

the person relaxing the hands, then the forehead, followed by the lower face, the neck, the stomach, and,

finally, the legs. For each muscle group, the person first tenses the muscles for 7--10 seconds, and then

relaxes them for about 15 seconds; paying attention to how the muscles feel. This is usually repeated for the

same muscle group two or three times in a relaxation session, which generally lasts 20 or 30 minutes. The

relaxation technique works best in a quiet, non-distracting setting with the person lying down or sitting on

comfortable furniture.

Stress management has been applied mainly with adults, but children also experience stress without being

able to cope effectively. Fortunately, many behavioral and cognitive methods are easy to learn and can be

adapted so that an adult can teach a young child to use them. Relaxation exercises provide a good example.

An adult could start by showing the child what relaxing is like by lifting and then releasing the arms and legs

of a rag doll, allowing them to fall down: Then, the adult would follow a protocol, or script, giving

instructions to relax. When children and adults first learn progressive muscle relaxation, they sometimes

don't actually relax their muscles when told to do so. Instead of letting their arms and legs fall down, they

move them down.

They also sometimes tense more muscles than they are asked to--for example, tightening facial muscles

when they are supposed to tense only hand muscles. These errors should be pointed out and corrected.

Often, after individuals have thoroughly mastered the relaxation procedure, they can gradually shorten the

procedure so they can apply a very quick version in times of stress, such as when they are about to give a

speech. This quick version might have the following steps: (1) taking a deep breath, and letting it out; (2)

saying to oneself, "Relax, feel nice and calm"; and (3) thinking about a pleasant thought for a few seconds.

In this way, relaxation methods can be directly applied to help people cope with everyday stressful events.

Research has demonstrated that progressive muscle relaxation is highly effective in reducing stress. What's

more, people who receive training in relaxation show less cardiovascular reactivity to stressors and stronger

immune function.

Systematic Desensitization

Although relaxation is often successful by itself in helping people cope, it is frequently used in conjunction

with systematic desensitization, a useful method for reducing fear and anxiety. This method is based on the

view that fears are learned by classical conditioning--that is, by associating a situation or object with an

unpleasant event. This can happen, for example, if a person associates visits to the dentist with pain, thereby

becoming "sensitized" to dentists.

According to Joseph Wolpe, an originator of the desensitization method, the reversal comes about through

the process of counter-conditioning, whereby the "calm" response gradually replaces the "fear" response.

Desensitization has been used successfully in reducing a variety of children's and adults' fears, such as fear

of dentists, animals, high places, public speaking, and taking tests.

An important feature of the systematic desensitization method is that it uses a stimulus hierarchy-- a

graded sequence of approximations to the conditioned stimulus, the feared situation. The purpose of these

approximations is to bring the person gradually in contact with the source of fear in about 10 or 15 steps.

To see how a stimulus hierarchy might be constructed, we will look at the one in the following example that

deals with the fear of dentists. The person would follow the instructions in each of the 14 steps.

Health Psychology PSY408

Example of a Stimulus Hierarchy for a Fear of Dentists

1. Think about being in the dentist's waiting room, simply accompanying someone else who is there for an

examination.

2. Look at a photograph of a smiling person seated in a dental chair.

3. Imagine this person calmly having a dental examination.

4. Think about calling the dentist for an appointment.

5. Actually call for the appointment.

6. Sit in a car outside the dentist's office without having an appointment.

7. Sit in the dentist's waiting room and hear the nurse say, `The hygienist is ready for you'.

8. Sit in the examination room and hear the hygienist say, -I see one tooth the dentist will need to look at.

9. Hear and watch the drill run, without its being brought near the face.

10. Have the dentist pick at the tooth with an instrument.

11. See the dentist lay out the instruments, including a syringe to administer an anesthetic.

12. Feel the needle touch the gums.

13. Imagine having the tooth drilled.

14. Imagine having the tooth pulled.

As you can see, some of the steps involve real-life, or in vivo, contacts with the feared situation and some

do not. Two types of non-real-life contacts, of varying degrees, can be included. One type uses imaginary

situations, such as having the person think about calling the dentist. The other involves symbolic contacts,

such as by showing pictures, films, or models of the feared situation.

The systematic desensitization procedure starts by having the person do relaxation exercises. Then the steps

in a hierarchy are presented individually, while the person is relaxed and comfortable. The steps follow a

sequence from the least to the most fearful for the individual. Each step may elicit some wariness or fear

behavior, but the person is encouraged to relax. Once the wariness at one step has passed and the person is

calm, the next step in the hierarchy can be introduced.

Completing an entire stimulus hierarchy and reducing a fairly strong fear can be achieved fairly quickly--it

is likely to take several hours, divided into several separate sessions. In one study with dental-phobic adults

who simply imagined each step in a hierarchy, the procedure successfully reduced their fear in six 1 1/2-

hour sessions. Individual sessions for reducing fears in children are usually much shorter than those used

with adults, especially for a child who is very young and has a short attention span.

Biofeedback

Biofeedback is a technique in which an electromechanical device monitors the status of a person's

physiological processes, such as heart rate or muscle tension, and immediately reports that information back

to the individual. This information enables the person to gain voluntary control over these processes

through operant conditioning. If, for instance, the person is trying to reduce neck-muscle tension and the

device reports that the tension has just decreased, this information reinforces whatever efforts the individual

made to accomplish this decrease.

Biofeedback has been used successfully in treating stress-related health problems. For example, an

experiment was conducted with patients suffering from chronic muscle-contraction headaches. Those who

were given biofeedback regarding muscle tension in their foreheads later showed less tension in those

muscles and reported having fewer headaches than subjects in control groups. What's more, these benefits

continued at a follow-up after 3 months. Biofeedback seems to be about as effective as progressive muscle

relaxation methods for treating headache.

Health Psychology PSY408

Modeling

People learn not just by doing, but also by observing. They see what others do and the consequences of the

behavior these models perform. As a result, this kind of learning is called modeling, and sometimes

"observational" or social learning.

People can learn fears and other stress-related behavior by observing fearful behavior in other individuals.

In one study, children (with their parents' permission) watched a short film showing a 5-year-old boy's

reaction to plastic figures of the cartoon characters Mickey Mouse and Donald Duck. In the film when the

boy's mother showed him the Mickey Mouse figure, he screamed and withdrew; but when she showed him

the Donald Duck figure, he remained calm and displayed no distress. While the subjects watched the film,

physiological measures of stress were taken, confirming that the children were more aroused while watching

the episode with Mickey Mouse (fearful) than while watching the one with Donald Duck. After the children

watched these scenes, they each participated in a task that involved the two figures from the film. At this

time, they tended to avoid the Mickey Mouse figure (the stressful one) in favor of Donald Duck.

Since people can learn stressful reactions by observing these behaviors in others, modeling should be

effective in reversing this learning and helping people cope with stressors, too. A large body of research has

confirmed that it is. The therapeutic use of modeling is similar to the method of desensitization:

The person relaxes while watching a model calmly perform a series of activities arranged as a stimulus

hierarchy--that is, from least to most stressful. The modeling procedure can be presented symbolically,

using films or videotapes, or in vivo, with real-life models and events.

Approaches Focusing on Cognitive Processes

Because stress results from cognitive appraisals that are frequently based on a lack of information,

misperceptions, or irrational beliefs, some approaches to modify people's behavior and thought patterns

have been developed to help them cope better with the stress they experience. To achieve this goal, these

methods guide people toward what Arnold Lazarus (1971) has called a "restructuring" of their thought

patterns or "Cognitive Restructuring".

Cognitive restructuring is a process by which stress-provoking thoughts or beliefs are replaced with more

constructive or realistic ones that reduce the person's appraisal of threat or harm.

A widely known approach that focuses on cognitive restructuring is rational-emotive therapy (RET), which

was developed by Albert Ellis. RET is based on the view that stress often arises from faulty or irrational

ways of thinking. These ways of thinking affect stress appraisal processes, increasing the appraisal of threat

or harm.

To illustrate how irrational thoughts can increase stress and lead to psychological problems, consider the

case of a college baseball player, nicknamed Bart," who was not hitting up to expectations, and was very

depressed about his poor performance. In talking with Bart, it quickly became apparent that his own

expectations were unrealistic.

For instance, Bart wanted to hit the ball so hard that it would literally be bent out of shape (if someone

happened to find it in the next county!). After a particularly bad batting session, he would go home and

continue to practice until he was immobilized with exhaustion. Simply put, he believed that if an athlete was

not performing well, this could only mean he was not trying hard enough.

Bart's therapy involved progressive muscle relaxation and cognitive methods to help him realize two

important things. First, although motivation and desire do increase performance, they do so only up to a

point, after which additional motivation impair performance. Second, although hitting very well is nice,

Health Psychology PSY408

hitting moderately well is not "terrible" or "intolerable". These realizations restructured Bart's thinking

about his performance, and his batting average increased dramatically. Similar methods can help people

reduce irrational thoughts that lead to their debilitating feelings of anxiety and depression.

There are other approaches also to manage stresses that include Meditation, Hypnosis, and Massage. These

approaches are and can be used in conjunction with the techniques described above. But we will not go into

the details of these approaches here.

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